医学ppt--basicchestxraymodadam.ppt

Basic Chest X-Ray InterpretationAdam Guttentag,M.D.All photos retain the copyrights of their original authors 2005 Adam Guttentag,MDHow do you look at a chest x-ray?Avoid tunnel vision!orHave a systemChest wall,bones and abdomenMediastinum,heart and hilaLungsThe Lateral Chest Film Find abnormalities hidden on the frontal filmConfirm abnormalities suspected from frontal filmDont be afraid to look at it!Our best friend!Looking at the lateral CXRHilar structures on the lateral film“Ring around the bronchus”Technical FactorsPositioning-straight vs oblique(How well try to fool you)Effect of obliquity on heart sizeTechnical FactorsPositioning-straight vs oblique-PA vs APTechnical FactorsPositioning-straight vs oblique-PA vs AP-erect vs supineerectsupineTechnical FactorsPositioning-straight vs oblique-PA vs AP-erect vs supine-lordotic vs kyphoticlordotickyphoticTechnical FactorsPositioning-straight vs oblique-PA vs AP-erect vs supine-lordotic vs kyphoticEffect on mediastinal contourTechnical FactorsDepth of inspirationVisualization of pathology depends on contrast provided by air in the lungsCount ribs!108Short of breathOne minute later8Technical FactorsBody habitusRadiographic technique:Is it really different?Changing technique can make disease look better or worse.Is the heart large?Is the mediastinum wide?Same patient,4 films within one monthRecognizing air space diseaseAlveolar spaces filled withsomething.Radiologists report:-“consolidation”-“air space opacity”-“fluffy density”-“infiltrate”Nonspecific:-Atelectasis,pneumonia,bleeding,edema,tumorThe Silhouette SignIndicates air space disease.Obscuration of a normally seen border,e.g.diaphragm or heart.Opacity with sharp edge along a fissure.Localizing disease from the silhouette signRLLRMLLLLLingulaLLLLocalizing disease from the silhouette signRULRMLULLLRML or lingula16 hours laterWhat happened here?Lobar AtelectasisBest sign shift of a fissureRapid development and clearanceAir bronchograms if non-obstructiveSecondary signs:-Mediastinal shift-Elevated diaphragm-Ribs closer together-Vague increased densityLLL AtxNext dayRUL AtxRML AtxLUL AtxPneumoniaSigns:-Air bronchogram-Silhouette-“positive”or“negative”-Dense hilum-“Spine”signAll are signs of any air space processDx of pneumonia depends on appropriate clinical scenario.Air bronchogram signPseudomonas pneumoniaLung cancerAir bronchograms CT PneumoniaLung cancerRight middle lobeRight upper lobeRight lower lobePosterior diaphragm silhouettedDense hilum,spine signDense hilum,spine sign againFour days laterFinal Exam21 y.o.with fever and coughHyperlucent hemithorax:why?Did you notice the mass?Lymphoma Take home message#1Its a chest x-ray,not a lung x-ray.6 cm lung mass missed.How?2 years agoTake home message#2Old films are your friend!Elderly man with hypotensionSuddenly septicPneumatosis of small bowelTake home message#3The patient pays forthe whole film!Review QuestionsAll are kinds of air space disease except:HemorrhagePneumoniaTumorSarcoidosis AtelectasisThe most specific sign of atelectasis is:Obscuration of a diaphragmShift of a fissureAir bronchogramsDensity over the spineMediastinal shiftThis can make the heart look larger than it is:Lordotic positioningAP positioningExpiratory filmSupine positioningAll of the aboveAdditional ReadingChest Roentgenology Felson,B W.B.Saunders Co,Philadelphia 1973 Chapter 2:Localization of Intrathoracic Disease.pp 22-70.Pare JAP and Fraser RG Synopsis of Diseases of the Chest W.B.Saunders Co,Philadelphia 1983.Chapter 4:Roentgenologic Signs in the diagnosis of Chest Disease.pp164-187.The EndUse the back button on the browser to exit the program